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Q.

When am I entitled to appeal my insurance company over a denial of care?

Related Topics: Insurance
 

Answers From Experts & Organizations (1)

Health Reform
888 Answers
635 Helpful Votes
21 Followers
A.

There are a number of circumstances under which you're entitled to appeal your insurer's decisions. You can appeal if your insurer:

  • Denied payment for your care
  • Ruled that your care was not medically necessary
  • Said that you're not eligible for the benefit in question
  • Claimed that your treatment is experimental
  • Claimed that you have a pre-existing condition (when your plan does not cover them)

By law, your insurer must review your appeal and make a determination within certain timelines:

  • 72 hours for denials of urgent care.
  • 30 days for denials of nonurgent care you have not yet received.
  • 60 days for denials of service you have already received.

If your insurance company has been paying for your care and made a recent decision to stop, it's always worth asking that it continue paying for your treatment until a determination on your appeal has been made.

This answer should not be considered medical advice...down arrowThis answer should not be considered medical advice and should not take the place of a doctor’s visit. Please see the bottom of the page for more information or visit our Terms and Conditions.up arrow

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Read the Original Article: Reader's Question on Denial of Care